Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting

Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.

Case Report: Lymphohistiocytic Myocarditis With Severe Cardiogenic Shock Requiring Mechanical Cardiocirculatory Support in Multisystem Inflammatory Syndrome Following SARS-CoV-2 Infection

Multisystem Inflammatory Syndrome (MIS) is a novel hyperinflammatory syndrome associated with SARS-CoV-2 infection. It predominantly affects children (MIS-C) a few weeks after a usually asymptomatic SARS-CoV-2 infection and is only rarely seen in adults above 21 years (MIS-A). Only scarce data on histological findings in both pediatric and adult patients has been published so far. An 18-year-old male patient was admitted to hospital in a febrile state, which progressed to severe cardiogenic shock and multi-organ failure requiring extracorporeal life support. Myocardial biopsy revealed small vessel-associated immune cell infiltrates. Diagnosis of MIS-C was made after ruling out all potential differential diagnosis. Use of immunosuppressive treatment with steroids, interleukin-1 blockade and high-dose intravenous immunoglobulins resulted in the patient's full recovery. Multisystem Inflammatory Syndrome (MIS) is a new differential diagnosis of cardiac dysfunction in pediatric and adult patients. The lack of myocardial necrosis differentiates the disease from other viral myocarditis and offers an explanation for the fast response to immunomodulatory therapy and the favorable prognosis. The preceding SARS-CoV-2 infection might only have been mildly symptomatic or even asymptomatic.

Pheochromocytoma and Takotsubo’s Cardiomyopathy Requiring Extracorporeal Membrane Support: A Report of Two Cases and Review of Takotsubo’s Cardiomyopathy Subtypes

Pheochromocytoma/Paraganglioma (PPGL) are rare neuroendocrine catecholamine secreting tumours that may vary widely in their clinical presentation. Previous case series describe 12% of PPGL patients initially presenting with cardiac complications. Pheochromocytoma-related Takotsubo’s cardiomyopathy has been well described in the literature and may present with primarily basal dyskinesis (inverted subtype), apical dyskinesis (classic subtype), or global dyskinesis. Basal dyskineses has been more commonly described in pheochromocytoma-related Takotsubo’s cardiomyopathy. We present two cases of severe cardiogenic shock requiring Extra-Corporeal Membrane Support (ECMO) with Takotsubo’s cardiomyopathy secondary to pheochromocytoma at University Health Network, Toronto. In both cases, the pheochromocytoma was incidentally discovered on imaging. Both patients responded favourably to ECMO and alpha-adrenergic blockade with recovery of ejection fraction. Both received adrenalectomy as an outpatient with successful recovery. Although rare, PPGL should be considered in younger patients presenting with severe unexplained cardiogenic shock and Takotsubo’s cardiomyopathy.

Single arterial access ECMELLA: A new concept and step-by-step procedure

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible.

Short-term use of “ECMELLA” in the context of fulminant eosinophilic myocarditis with cardiogenic shock

Background Eosinophilic myocarditis (EM) is a rare form of myocarditis. Clinical presentation is various, includes cardiogenic shock and can often be fatal. Diagnosis is based on myocardial eosinophilic infiltration in endomyocardial biopsy. Mechanical circulatory support (MCS) is often required in patients suffering from severe cardiogenic shock. Among the available MCS options the “ECMELLA” concept, a combination of left ventricular venting by Impella® device and extracorporeal life support (ECLS) is possibly able to provide the necessary time frame for diagnostics and initiation of anti-inflammatory medication in patients with fulminant myocarditis. Case presentation We report a case of a 38‐year‐old woman who was presented to us in severe cardiogenic shock, quickly requiring hemodynamic support by an Impella CP® device. Further dramatic hemodynamic deterioration accompanied by multi-organ dysfunction required escalation of MCS via ECLS as veno‐arterial extracorporeal membrane oxygenation (VA-ECMO). After histopathological diagnosis of EM, our patient was put on immunosuppressive therapy with prednisolone. Recovery of both right and left ventricular function allowed explanation of VA-ECMO on day 4 and further hemodynamic improvement allowed removal of the Impella® device on day 9. The patient was discharged after 7 weeks with fully restored cardiac function and in a good neurological state. Conclusions In severe cardiac shock due to fulminant EM the ECMELLA concept as bridge-to-recovery seems to be a valid option to provide the required time for diagnostics and specific therapy.